• Site conducted

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Survey Team


General Safety

  • Sinks: Sinks secured / locked and no items stored under sinks?

  • Equipment / Furniture:<br> * All equipment/furniture in good condition/functional and no broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips, cracks, chipped, stains or repairs needed (broken).

  • Solid Waste: Appropriate items in general waste receptacles.

  • Soiled Utility: Appropriate items in linen storage bins, bin capacity (32 US gallons) and maximum quantity enforced (2 bins per 10' x 10' room).

  • Refrigerators Patient Use: Contain only items permitted for placement/storage i.e., specimens, medications, formulas, or patient food items

  • Refrigerators Staff Use: Personal items are clearly labeled, use of shopping/plastic bags are strictly prohibited, and refrigerator is well maintained and kept clean at all times

  • Refrigerator Temperature Monitoring: Temperature logs are completed daily and action is taken and documented when temperature is out of range

  • Lighting: Is lighting suitable for patient care, treatment and services

  • Air Quality: Unit air is free from offensive odors

  • Compressed Gas Cylinders: Medical oxygen/compressed gas cylinders stored in designated storage location, all cylinders in use are used with proper cart or secured to prevent falling/toppling

  • Compressed Gas Cylinders: Medical oxygen/compressed gas cylinders are stored with full and empty cylinders separated and does not exceed the maximum of 12 E cylinders per smoke compartment

  • Compressed Gas Cylinders: Empty medical oxygen/compressed gas cylinders are labeled “empty”/have tags indicating appropriate label (full, in-use, empty)

  • Ceiling Tiles: All ceiling tiles are in place, clean, dry, with no stains or holes / penetrations

  • Appliances and Patient Equipment/Products: All electric or electronic staff and patient furnished appliances or consumer products have been inspected, approved for use, and labeled accordingly prior to use based on known area restrictions

  • Power Strips: Power strips used on non-patient care equipment outside of patient care vicinity UL listed

Medical Equipment

  • Medical Equipment: All equipment in good condition and operational

  • Medical Equipment Safety & Maintenance Inspection Tags: All equipment safety and maintenance inspection tags in place and current

  • Medical Equipment Maintenance: Staff can identify whether and when medical equipment is due or past due for service

  • Medical Equipment Failure Procedures: Staff can demonstrate or describe emergency procedures to follow in the event of medical equipment failure

  • Medical Equipment Incidents: Procedures for reporting patient device malfunction and equipment incident problems are known to the staff and reported to Biomed

  • Blanket Warmers: Set to maintain temp of 130, temperature logs completed routinely and out of range temperature readings addressed as required

  • Nurse Call: Nurse call system, lights, and call cords in place and functional

  • Clinical & Equipment Alarms: Staff can describe or demonstrate checking and documenting clinical alarms and identify which critical equipment have alarms

  • Equipment Power Cords: All power plugs are 3 pronged for patient care equipment and cords are in good visual condition


  • Power Strips: Power strips are only used on moveable patient care equipment, are permanently attached to the equipment, and are UL 1363A 0r UL 60601-1

  • Electrical Panels: All electrical panels are accessible maintaining a 36” clearance in front of panel(s) and panels are secured/locked to prevent tampering

  • Emergency Outlets: Staff can identify emergency (red) electrical outlets/receptacles

  • Medical Gas Valves: All medical gas valves are properly labelled (by zones)

  • Medical Gas Valves: Staff can describe or demonstrate medical gas zone valves, rooms they serve, and who is authorized to operate the valves

  • Air Quality: Air pressure monitoring devices are not in alarm condition and devices are operating correctly

  • Restrooms: Showers, sinks and water closets are free from leaks

  • Electrical Outlets and Switches: Lights switch covers and outlet receptacles in place with no exposed wires

  • Electrical Outlets: Electrical outlets and receptacles within 6 ft of a water source (sink) has GFCI protection.

Hazardous Materials & Waste

  • Staff Training: All staff have completed universal precaution, blood borne pathogen, and hazard communication training and training records are readily available

  • Medical Waste: Only appropriate/approved items placed in biohazard waste receptacles

  • Hazardous Rooms/Areas: Secured/locked

  • Hazardous Labeling: Biohazard receptacles/containers properly labeled. Hazardous substances properly labeled, stored and handled.

  • Red Bags: Staff have been educated on what materials can and/or cannot be placed into the red bags.

  • Sharps: Sharp containers not overfilled, no more than ¾ full

  • Eyewash/Shower Stations: Staff know the location of the nearest emergency eye wash/shower station and weekly inspection tags/logs present and up to date

  • Safety Data Sheets: Staff know where to find SDS and inventory listing is current

  • Spill Response: Staff are aware of department specific spill response procedures

  • Flammable and Corrosives: Properly segregated, and properly stored with SDS readily available

  • Chemical Labeling: Staff are aware of properly labeling secondary containers used for hazardous chemical and all bottles/containers are properly labelled

  • Chemical Use: Staff are knowledgeable on appropriate selection, handling, storing, transporting, use, and disposal processes for hazardous materials

  • Hazardous Medications: Hazardous medication are properly disposed

Fire Safety / Life Safety

  • PPE Availability: Appropriate personal protective equipment is readily available with adequate quantities and in good condition

  • Fire Sprinklers: Sprinkler heads are free from excessive dust/paint and all sprinklers have the appropriate escutcheon plates/rings

  • Exits & Smoke Compartments: Staff know where nearest exit(s) and adjacent smoke compartment(s) are located, exit signs are lit and clearly visible

  • Means of Egress: Fire exits are clearly marked, unlocked from inside, aisles/corridors are clear without obstructions

  • Means of Egress: Hallway/Corridor clearance – no equipment not in active use is permitted in the hallway. Permitted items must be staged only on one side.

  • Fire Doors: All doors operate as designed, have positive latching, propped open doors and paper signs attached to doors is strictly prohibited

  • Fire Extinguishers: Fire extinguishers are in proper place, safety inspection tags in place and current, clear access unobstructed access to extinguishers

  • Walls: Walls are free from holes/penetrations and cleanliness is maintained

  • Exit Signs: Exit signs are properly mounted, clearly visible, and illuminated.

  • Storage Rooms: Combustible materials are properly stored and kept to a minimum

  • Storage Rooms: Materials stored on shelves comply with the 18” fire sprinkler clearance requirement, items stored directly is monitored and prohibited

  • Fire Drills: Staff understand the acronym of RACE & PASS

  • Fire Response Plan: Staff are knowledgeable on location of fire alarm pull stations, primary fire exits, and location of evacuation chairs

  • Medical Gas Shut Off Valves: Staff aware of locations of emergency shut off valves for medical gases and who is authorized to turn off supply

  • Fire Response Plan: Fire alarm pull stations, fire extinguishers, medical gas shutoff valves have clear access and not blocked or obstructed


  • Corridors: Corridors are free from obstruction. Work Station on Wheels (WOWs) are removed from the egress corridors in the event of fire alarm activation(s). 30 minute rule applies.

  • Security Access Controls Systems: All access controls systems (swipe cards) and ADA disability push plates/auto doors, are functioning properly

  • Security Access Controls Systems: Maglocks and motion detectors are functioning properly

  • Employee ID Badges: All employees are wearing identification badges and all badges are clearly visible

  • Visitor/Contractors Daily Pass Program: All visitors and contractors are wearing appropriate tags and are monitored for compliance

  • Security Request Procedure: Employees can demonstrate how to request security and how to report security and safety incidents using the Incident Reporting System (IR)

  • Restricted Areas: Restricted areas/controlled access rooms/areas are properly identified and secured

  • Medication Rooms: Medication rooms are continuously monitored and secured

  • Security Alarms: Security alarms at exit doors are functioning properly

  • Crash Carts: Crash carts are secured when not in use

  • Exit Doors: Exit doors close and lock properly


Emergency Preparedness

  • Emergency References: Emergency reference guides are available and staff know where to locate/find them.

  • Staff aware of GRMC's Emergency Operation Plans (EOP) & response procedures and/or know where to locate the EOP

Emergency Codes (Staff Knowledge)

  • Staff know what a CODE RED is. (Fire)

  • Staff knows unit specific response to CODE RED?

  • Staff know what a CODE YELLOW is. (Utility Failure)

  • Staff knows unit specific response to CODE YELLOW?

  • Staff know what a CODE GREEN is. (Elopement)

  • Staff knows unit specific response to CODE GREEN?

  • Staff know what a CODE BLUE is. (Medical Emergency)

  • Staff knows unit specific response to CODE BLUE?

  • Staff know what a CODE GRAY is. (Disruptive Person)

  • Staff knows unit specific response to CODE GRAY?

  • Staff know what a CODE BLACK is. (Bomb Threat)

  • Staff knows unit specific response to CODE BLACK?


Patient Rooms

  • Horizontal and vertical surfaces are clean; Nothing on window sills


  • If cleaning checklist is used, is it signed off

  • Trash cans not overflowing

  • Bathroom is clean

  • Hand hygiene products available, PPE available as needed

  • No overfilled sharps containers

  • No open sterile saline or sterile water left in room

  • Privacy curtains tagged with cleaning schedule (hung & change date)

Isolation Rooms

  • Appropriate signage in place

  • PPE stocked, red bags easily accessible

  • Trash and linen handled per policy

  • Appropriate PPE used by staff

  • Appropriate patient/family education

  • Airborne precautions:<br> Door is closed<br> Negative pressure is monitored<br> Appropriate air exchange

Hand Hygiene

  • Sinks for handwashing are appropriately stocked with soap, paper towels, trash cans

  • Sinks are available in patient’s room and all areas as needed

  • Alcohol hand sanitizers are available in all areas as needed and not expired

  • Placement of alcohol hand sanitizer is compliant with safety recommendations

  • Handwashing/hand hygiene is monitored by staff for compliance

  • No unapproved lotions

Nourishment Room

  • Door to room is labeled

  • Refrigerator has single use (medications, foods, specimens)

  • Items are appropriately labeled, not expired

  • Refrigerator is clean and defrosted (if necessary)

  • Ice machine clean

Linen (Clean)

  • Door to room is labeled

  • Linens are in good condition

  • Stored on covered cart or in linen room

  • Covered for transport

Linen (Soiled)

  • Door to room is labeled

  • In hamper with impervious liner or hamper is cleaned on specific schedule

  • Hamper is covered

  • Soiled linen covered for transport

  • Soiled linen is bagged at bedside

  • Removed from unit on specified schedule

Administrative Areas: Offices, Conference Rooms, Nurses Station

  • Horizontal and vertical surfaces are clean

  • Trash cans are not overflowing

  • Uncluttered

  • Bathrooms are clean, hand hygiene products are available

Hazardous Materials & Biomedical Waste

  • Storage areas have appropriate signage

  • Biomedical waste is handled per policy, picked up for transport on specified schedule

  • Appropriate sharps containers in use

  • Sharps containers no more than ¾ full

  • Sharps containers secured for transport

  • Locate blood, chemical spill kit

Cleaning & Disinfection

  • Medical equipment in good working condition

  • Appropriate processes in place for low level cleaning and disinfection

  • Employee protection measures are implemented

  • Preventive maintenance program in place

Supply / Storage Rooms

  • Door to room is labeled

  • Storage areas are clean and uncluttered

  • Supplies are at least 18” from sprinkler heads

  • Supplies are stored off the floor

  • No corrugated and outside shipping boxes

  • General Supplies or Patient care supplies not expired, damaged, soiled, or compromised.

  • Plastic/impermeable liners are present on all bottom shelves

Clean Utility Room

  • Door to room is labeled

  • Environment is clean

  • Clean equipment is tagged/bagged as ready to use

  • No storage of patient personal belongings

  • No corrugated and outside shipping boxes

  • All supplies off the floor

  • Supplies are not stored under sinks

Soiled Utility Room

  • Door to room is labeled

  • Biohazard symbol on door if biomedical waste in room

  • Soiled linen in hamper with impervious liner or hamper is cleaned on specific schedule

  • Room is uncluttered / Appropriate use of utility room

  • Clean supplies not in room

  • Appropriate PPE available

Waiting Areas

  • Horizontal and vertical surfaces are clean

  • Trash is not overflowing

  • Area is uncluttered

  • If appropriate, supplies for respiratory hygiene available and posted instructions in place

Public / Patient Restrooms

  • All surfaces are clean

  • Handwashing supplies are available and not expired

  • Trash is not overflowing

  • Duress / emergency pull cord not wrapped around hand rail.

  • If cleaning checklist is used, appropriately signed off

Staff Interviews

  • Staff are able to locate IC Manual (P&P)

  • Staff can find the Infection Prevention patient/family education and resources

  • Staff know when soap and water for hand hygiene is to be used (pt. w/C. diff/diarrhea/visibly soiled)

  • Staff knowledgeable with the process if they accidentally stick themselves with a needle

  • Observe nail policy enforced (nails less than ¼”, no artificial nails, no cracked or chipped nail polish)

  • Staff knows when someone is in isolation

  • Staff knows how frequently they should clean patient equipment (between patients, visibly soiled at minimum)

  • Staff know about appropriate linen storage

  • Staff aware of who oversees cleaning equipment

  • Staff able to state Standard Prec. Practice for PPE

  • Staff able to state Contact Prec. Practice for PPE

  • Staff able to state Airborne Prec. Practice for PPE

  • Staff able to state Droplet Prec. Practice for PPE

  • Staff knowledgeable about who are allowed in an airborne isolation negative pressure room

  • Staff able to state contact time for Sani-Cloth Wipes (3 minutes)

  • Staff know that gloves should be worn when using Sani-Cloth Wipes

Medication Room

  • Door to room is labeled

  • Horizontal and vertical surfaces are clean

  • Medication refrigerator is clean and tidy

  • No food stored in medication refrigerator

  • Sink for handwashing is appropriately stocked with soap, paper towels, trash cans

  • Admixture areas is clean and uncluttered

  • Pill cutters are clean, free of any medication residual

  • Pill crusher is clean, free of dust

Janitor Room

  • Door to room is labeled

  • Cleaning equipment stored appropriately

  • Environment is clean

  • Room is uncluttered

Staff Lounge, Staff Food & Drink

  • Door to room is labeled

  • Horizontal and vertical surfaces are clean

  • Sink for handwashing is appropriately stocked with soap, paper towels, trash cans

  • Trash is not overflowing

  • Refrigerator is clean and defrosted (if necessary)

  • No food stored over 48 hours. If food is stored, bag is labeled with expiration within 48 hours of storage

  • Microwave is clean

  • Bathroom is clean

  • No crumbs or food is left out to attract ants or other insects like flies or cockroaches

  • Area is uncluttered

  • Food limited to staff lounges, conference rooms, private offices

  • Covered drinks in nursing station limited to low surfaces; no drinks on high surfaces or where drinks can be contaminated (i.e. near specimen pick-up areas)

  • No drinks near patient’s room (i.e. chart racks, WOW’s, shelves between patient rooms)


Protected Health Information (PHI)

  • Confidential Patient Information cannot be seen by unauthorized persons (papers laying around containing PHI)<br>

  • Computer terminals signed off when not in use/not left unattended

  • Patient information is not discussed in public areas where it can be overheard

  • Labels and PHI are obliterated/shredded before discarding in regular trash or appropriately discarded into the shredding bin

  • No clipboards displayed as sign-in sheets when multiple patient names on the list.

  • If fax machine is in public area, patient information is quickly removed.


Knowledge Quiz

  • Staff know what the two acceptable patient identifiers are for GRMC. (answer: Full Name and Date of Birth)

  • Staff know the acceptable time frame to report a critical result. (answer: 15 minutes except from Radiology which is 30 minutes)

  • Staff know how label a multi-dose vial. (answer: Labeled with an expiration date of 28-days from the date opened)

  • Staff know what the primary way to prevent infection. (answer: Hand hygiene/washing hands thoroughly)

  • Staff aware that patients assessed to be at risk for suicide should have the appropriate colored alert on the patient's ID wristband. (answer: Orange colored alert on the wristband)

  • Staff know what a "Time Out" is. (answer: it's a final assessment to verify that you have the correct patient, correct site, and correct procedure prior to incision/surgery)


  • The unit/department's quality improvement dashboard project is posted in unit.

  • Are staff able to speak about their unit specific quality indicators? (Do they know what their quality indicators are?)

  • Are staff aware of the other units/departments' quality indicators or at least know where to find it? (Found in the intranet homepage under "QI SharePoint")


Medication Room

  • Medication refrigerator temperature log is current, in range, and action is documented when a discrepancy is noted.

  • Medication refrigerator: Only contain medications for current patients.

  • Laminar flow hood is used for IV admixture when appropriate.

  • Visual inspection of medication containers/outer plastic wraps for IV solutions: No Issues/Uncompromised.

  • Medications stored appropriately to maintain stability.

  • Medication is appropriately labeled (i.e. expiration dates, directions, etc.)

  • All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.

  • Controlled substances are stored to prevent diversion.

  • Medications, formula, & solutions not expired beyond expiration date.

  • Opened multi-dose vials dated and initialed and is not expired.

  • Syringes are labeled when in use.

Code Carts

  • Code carts are locked and marked with the first drug to expire.

  • Code Carts are checked per policy.

  • Defibrillators are checked per policy.

  • Nothing expired found in/on the code cart.

  • Medication Carts: Doors and drawers are locked.

  • Code Cart is clean not untidy.

  • Oxygen tank is present on cart, secured, not expired, and appropriately labeled (green tag).


  • Patients and families were properly informed of their rights.<br> * Rights and Responsibilities statement

  • Family guides/materials were provided to all families on admissions.

  • The patient was asked if they have a living will or advanced directives upon admission.

  • The patient was provided with an informed consent prior to medical treatment (i.e. surgery). (If applicable, surveyor should request to look at the informed consent with all appropriate elements as well as signatures present.)


  • Point of Care testing lab controls documented and control solution labeled & dated. (i.e. Reagents, i Stat analyzes, glucometers, GEMS)

Point of Care Testing Quality Control

  • Consistently and correctly documented<br>

  • Dates not missing initials

  • Performed by qualified person

  • Out of range is followed

  • Logged numbers match bottle ID numbers


  • Greet the team with smiles and introductions.

  • Have a space designated for the team to conduct interviews and file reviews.

  • Promptly deliver materials asked for or required for review to the tracer team.

  • No additional comments regarding positive or suboptimal issues observed during the tracer.

  • No additional comments regarding positive or suboptimal issues observed during the tracer.

  • No additional comments regarding positive or suboptimal issues observed during the tracer.

  • No additional comments regarding positive or suboptimal issues observed during the tracer.

  • No additional comments regarding positive or suboptimal issues observed during the tracer.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.